The FAST exam was recommended in 21 out of 22 local guidelines. In addition, our study revealed three main findings. First, different specialties seem to perform ultrasound examinations in different trauma facilities. Second, we found various indications for performing FAST, ranging from all “abdominal trauma” to “trauma leader’s discretion.” Third, we found that documentation of ultrasonography examinations and storing of images was sparse.
An e-mail survey from 2008 in the U.S. showed that 85% of hospitals reported using the FAST examination for trauma care [2]. Our investigation showed a recommendation of FAST in 95.5% of all facilities receiving traumatized patients in Denmark. The higher percentage in our study probably reflects the growing interest in ultrasonography over time. Repetition of the American study might reveal a higher percentage today, which is why we consider the difference as a reflection of general development in the area.
Our study revealed differing local recommendations regarding which specialties should perform the ultrasound examinations. We have not come across evidence in the literature that one specialty should outperform others. We found that fewer surgeons and radiologists, and more anesthesiologists, perform FAST examination according to interviews than according to the local trauma care guidelines. Earlier work has shown that the vast majority of physicians performing ultrasonography in the Emergency Department are anesthesiologists [19]. Our study suggests that in trauma it will more often be the person with the greatest skill who performs the FAST examination rather than the person recommended in the guidelines. These findings might reflect that anesthesiology often is the specialty present with the most experience, while radiologists may be on call but not present in the trauma room.
The FAST exam is user dependent, and the specificity and sensitivity are related to the experience of the provider. The examination has low sensitivity for organ injury without hemoperitoneum and low sensitivity for retroperitoneal bleeding [6]. To reach an overall sensitivity of 67% and specificity of 100%, extensive experience of more than 100 FAST examinations is necessary [21]. A reliable and validated assessment tool for assessment of competency in point-of-care ultrasonography exists [22]. This evidence calls for a specification in the existing guidelines recommending the most experienced person to perform the examination. Preferably, the experience should be quantified, and an expected minimum of experience or a minimum required competency level should be outlined.
The indications for performing FAST differ between facilities, and, including extended FAST, views of the thorax are also heterogenic. Some facilities recommend other use of sonography beyond FAST, such as sonography of the scrotum. The addition of extended FAST views appears helpful in the literature as life-threatening injuries such as tension pneumothorax or massive hemothorax can be diagnosed at the bedside [11, 23]. Cardiac evaluation alone in penetrating trauma to the chest has been shown to decrease mortality [24]. Although the eFAST exam for trauma has not been shown to reduce mortality, it still has several advantages. Knowledge of thoracic injury with pneumothorax, hemothorax, or pericardial effusion at the time of arrival can be used to guide initial treatment even before a CT scan is performed. Future trials should seek to illuminate the clinical strength of the full eFAST over the FAST alone.
To our knowledge, the frequency of ultrasonography images being stored and documented has not previously been investigated in the trauma setting. Recommendations have been published on how to store images and document examinations [25], but these are not followed. Our findings, which show a surprisingly low frequency of storage and documentation, call for attention to the problem in the local guidelines. Without proper documentation, developing the field is immensely difficult. Furthermore, lack of image storing may present legal issues in the future.
Our study has limitations. First, the study is national and limited to the Danish hospitals receiving traumatized patients. However, our findings of particular problems in heterogeneity between facilities and scanty documentation undoubtfully exist abroad, and our call for national guidelines can only inspire other countries to do the same. A second limitation is ascribing value to interviews of the trauma team leaders and other doctors on call. We do not know whether the results would have been different if the phone call had been made on a different day or whether the answers were influenced by recollection bias.
